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Environmental Triggers
of Asthma
Acknowledgments
Accrediting
Organization
Credits Offered
Accreditation
Council for
Continuing
Medical
Education
(ACCME)
American
Nurses
Credentialing
Center (ANCC),
Commission on
Accreditation
National
Commission
for Health
Education
Credentialing,
Inc. (NCHEC)
International
Association for
Continuing
Education and
Training
(IACET
Table of Contents
Initial Check ........................................................................................ 8
Overview of Asthma ............................................................................ 13
Differential Diagnosis of Asthma ........................................................... 16
Environmental Triggers of Asthma ........................................................ 20
Clinical Assessment ............................................................................ 34
Case Study (Continued) ...................................................................... 42
Treatment, Management, and Prevention .............................................. 45
Sources of Additional Information ......................................................... 59
Literature Cited .................................................................................. 65
Table of Tables ................................................................................... 76
Posttest ............................................................................................. 76
Availability
Instructions
Instructional
Format
follows
Section
Element
Title
Purpose
Serves as a focus question that you should be able to
answer after completing the section
Learning
Objectives
Text
Key Points
Progress Check
exercises
Progress Check
Answers
Learning
Objectives
Content Area
Overview of
Asthma
Differential
Diagnosis of
Asthma
Environmental
Triggers of
Asthma
Objectives
Define asthma
Identify environmental factors that trigger asthma
Clinical
Assessment
Treatment,
Management,
and Prevention
Initial Check
Instructions
Case Study
Sneezing,
Itchy eyes, and
Clear discharge from the nose.
Initial Check
Answers
infections,
Foreign body aspiration, and
Wheezing associated with gastroesophageal
reflux.
Overview of Asthma
Learning
Objectives
Purpose of This
Case Study
Asthma assessment,
Monitoring,
Pharmacotherapy,
Asthma education and,
Implementation of asthma guidelines in health care
systems.
Definition of
Asthma
Factors That
Contribute to
Asthma
Cockroaches,
Dust mites,
Pollens,
Animal dander, and
Molds [Murray et al. 2001; Togias 2003; Jaakkola
et al. 2005],
Exercise,
Food allergies,
Gastroesophageal reflux,
Aspirin, or
Other nonsteroidal anti-inflammatory drug
(NSAID) sensitivity, sulfite sensitivity, and others
[Weinberger 2003; NHLBI 1997].
Progress Check
1.
Wheezing.
Seizures.
Shortness of breath.
Cough.
Allergens.
Irritant chemicals.
Viral infections.
All of the above.
Differential
Diagnosis in
Adults
Differential
Diagnosis in
Children
Pulmonary embolism,
Pulmonary infiltrates with eosinophilia, and
Some medications (e.g., angiotensin-converting
enzyme (ACE) inhibitors) [NHLBI 2007].
Viral bronchiolitis or
obliterative bronchiolitis
Cystic fibrosis
Bronchopulmonary dysplasia
Other causes
Adults
Chronic obstructive
pulmonary disease (COPD)
Hyperventilation syndrome
and panic attacks
Congestive heart failure
Pulmonary embolism
Laryngeal dysfunction
Mechanical obstruction of the
airways (benign and
malignant tumors)
Pulmonary infiltration with
eosinophilia
Diffuse parenchymal lung
diseases
Cough secondary to drugs
(ACE inhibitors)
Vocal cord dysfunction
Dysfunction or
gastroesophageal reflux
Key Points
Progress Check
3.
Introduction
Allergens such as
o
o
o
o
o
Pollen,
Mold,
Animal dander,
Insect parts, and
Some chemicals
Irritants such as
o
o
o
o
Models of Effect
Evidence of
Effect
Smoke,
Dust,
Gas or Diesel fumes, and
Chlorine
Biologic
Allergen
Overview
Home,
School, and
Work and recreational environments
although concentrations of
Dust mites,
Cockroaches, and
Animal dander allergens (pets, mice, rats) vary with
geographic location.
However,
Dust Mites
Cockroaches
Soft toys,
Upholstered furniture,
Bedding,
Mattresses, and
Carpets [Sporik et al. 1990; Platts-Mills et al. 1995;
Duffy et al. 1998].
Wheezing,
Missed school days,
Emergency room visits, and
Hospitalizations
Cats
Other Animals
Molds
Penicillium,
Aspergillus,
Cladosporium, and
Alternaria.
Nasal congestion,
Runny nose,
Conjunctivitis
Sneezing,
Lacrimation,
Wheezing,
Chest tightness, and
Shortness of breath.
Environmental
Tobacco Smoke
(ETS)
Combustion
Devices
Sinusitis,
Otitis media, and
Bronchiolitis [IOM 2000; Tager et al. 1993].
Chemical Fumes
Miscellaneous
Allergens
Outdoor Air
Pollution
Gloves,
Balloons,
Condoms, and
Various types of sporting equipment [Landwehr and
Boguniewicz 1996].
Castor beans,
Soybeans, and
Grains
Aldehydes,
Metals,
Uncombusted hydrocarbons,
Isocyanates, and
Others [Leikauf et al. 1995].
1992].
Air pollution has been implicated as one of the factors
responsible for the increase in asthma incidence in most
industrialized countries [Salvi 2001]. Clinicians should be
aware of the common (criteria) air pollutants that may
affect asthmatic patients. The National Ambient Air
Quality Standards (NAAQS) are set for six criteria
pollutants:
Ozone (O 3 ),
SO 2 ,
NO 2 ,
CO,
Particulate matter <10 microns (PM 10 ) and
particulate matter <2.5 microns (PM 2.5 ).
Index figures,
Critical pollutant, and
Specific groups sensitive to the pollutant [US EPA
1999].
Levels of Health
Concern
Colors
...air quality
conditions are:
...as symbolized
by this color:
0 to 50
Good
Green
Ozone
51 to 100
Moderate
Yellow
101 to 150
Unhealthy for
Sensitive Groups
Orange
151 to 200
Unhealthy
Red
201 to 300
Very Unhealthy
Purple
301 to 500
Hazardous
Maroon
NO2
Most NO 2 health effects are believed to be due to longterm, low-level outdoor exposure. Like the other air
pollutants, NO 2 increases bronchial responsiveness during
exercise. NO 2 decreases lung function in persons with
asthma exposed to concentrations above 0.3 ppm,
although there is not a clear dose-response relationship.
Short-term exposure to high concentrations of NO 2
induces terminal bronchiolar changes and diffuses
alveolar injury. Such high concentrations are generally
seen only in accidental exposure, as might occur within
confined spaces or in an occupational setting [Etzel 2003;
Shima and Adachi 2000].
PM 10 and PM 2.5
Transition metals,
Hydrocarbons,
Ultrafine particles, and
Endotoxin
Vehicle exhaust,
Forest and vegetation fires, and
Atmospheric reactions between gases (SO 2 and NO x )
and VOCs.
Traffic-Related
Pollutants and
Diesel Exhaust
Occupational
Asthma
Aldehydes,
Animal and vegetable proteins,
Cleaning agents,
Detergent enzymes,
Diisocyanates,
Epoxy glues,
Flour,
Hair dressing products
Latex,
Platinum salts, and
Wood dust.
Key Points
Progress Check
3.
4.
Latex.
Spider mites.
Diisocyanates.
Epoxy.
Clinical Assessment
Learning
Objectives
Key Elements
of Diagnosis
Medical
History
Physical Exam
Pulmonary
Function
Testing
Allergy
Testing
Age,
Height,
Race, and
Sex [NHLBI 2007].
Diagnosis and
Evaluation of
Occupational
Asthma
Key Points
Progress Check
5.
Tobacco smoke.
Pets.
Bedding and laundering practices.
All of the above.
7.
Case Study
Follow-Up
Progress Check
9.
Cats.
Environmental tobacco smoke.
Mold in the bathroom.
Lead paint around window sills.
Up in this section.
Treatment and
Management
Overview
Causing,
Triggering, and
Exacerbating asthma.
2011].
Goals for the general management of a patient with
asthma include
Predisposing
Factors
Exposure to
Allergens and
Risk of Asthma
Hygiene
Hypothesis
Age of exposure,
Timing of exposure relative to disease development,
Dose and frequency of exposure,
Co-exposures, and
Genetic predispositions in response [Song and Liu
2003].
Primary
Prevention
Strategies in
Children
Sinusitis,
Otitis media,
Bronchiolitis, and
Diminished pulmonary function.
Primary
Prevention in
Adults
Isocyanates,
Enzymes, or
Latex.
Pollutants,
Irritants, and
Allergens
Animal
Allergens
Remove humidifiers.
Replace wool or feathered bedding with synthetic
materials that will withstand repeated hot water
washing.
Use a damp mop or rag to remove dust (a dry cloth
just stirs up mite allergens).
Vacuum regularly using a cleaner with a HEPA filter
or a double-layered microfilter bag (try not to
vacuum when the asthmatic is in the room).
Wash and thoroughly dry stuffed toys weekly in hot
water, or freeze them weekly.
Wash bedding in hot water (at least 130F) weekly.
Cockroach
Allergen
Food
Pest management
Environmental
Tobacco Smoke
Indoor Air
Pollution
Outdoor Air
Pollution
Desensitization
Key Points
Progress Check
CDC-INFO http://www.cdc.gov/cdc-info/
800-CDC-INFO (800-232-4636) TTY 888-2326348 - 24 Hours/Day
Email: cdcinfo@cdc.gov
PLEASE NOTE
ATSDR cannot respond to questions about
individual medical cases, provide second
opinions or make specific recommendations
regarding therapy. Address these issues
directly with your health care provider.
http://www.cdc.gov/asthma/default.htm
o National Asthma Control Program
http://www.cdc.gov/asthma/nacp.htm
Key Clinical Activities for Quality Asthma Care.
http://www.cdc.gov/mmwr/preview/mmwrhtml
/rr5206a1.htm
o NIOSH
General
Environmental
Health
Information
http://www.atsdr.cdc.gov/csem/csem.asp?csem=
26&po=0
o To view the complete library of CSEMs
http://www.atsdr.cdc.gov/csem/csem.html
o Exposure History Worksheet
http://www.atsdr.cdc.gov/csem/exphistory/docs/
CSEMExposHist-26-29.pdf
o ATSDR Division of Regional Operations.
Literature Cited
References
Suppl):37.
Lemiere C. 2004. The use of sputum eosinophils in the
evaluation of occupational asthma. Curr Opin Allergy
Clin Immunol 4(2):815.
Lindren S, Belin L, Dreborg S, Einarsson R, Pahlman I.
1988. Breed-specific dog-dandruff allergens. J Allergy
Clin Immunol 82:196204.
Liu AH, Murphy JR. 2003. Hygiene hypothesis: fact or
fiction? J Allergy Clin Immunol 111(3):4718.
Lodrup Carlsen KC, Carlsen KH. 2001. Effects of
maternal and early tobacco exposure on the
development of asthma and airway hyperreactivity. Curr
Opin Allergy Clin Immunol 1(2):13943.
Luft C, Hausding M, Finotto S. 2004. Regulation of T
cells in asthma: implications for genetic manipulation.
Curr Opin Allergy Clin Immunol 4(1):6974.
Malo JL, Chan-Yeung M. 2006. Appendix: Agents
causing occupational asthma with key references. In
Asthma in the Workplace and Related Conditions, 3rd
Edition. Edited by Bernstein DI, Chan-Yeung M, Malo JL, Bernstein IL. New York NY:Taylor and Francis. p.
825866.
Malo JL, Chan-Yeung M. 2001. Occupational asthma. J
Allergy Clin Immunol 108(3):31728.
Mapp CE, Boschetto P, Maestrelli P, Fabbri LM. 2005.
Occupational asthma. Am J Respir Crit Care Med.
1;172:2805.
Martinez FD, Cline M, Burrows B. 1992. Increased
incidence of asthma in children of smoking mothers.
Pediatrics 89:216.
Martinez FD. 2003. Respiratory syncytial virus
bronchiolitis and the pathogenesis of childhood asthma.
Pediatr Infec Dis J 22(2 Suppl):7682.
Epidemiology 11:610.
Shah R, Grammer RC. 2012. An overview of allergens.
Allergy Asthma Proc 33:S2S5.
Shima M, Adachi M. 2000. Effect of outdoor and indoor
nitrogen dioxide on respiratory symptoms in
schoolchildren. Int J Epidemiol 29:86270.
Shusterman D. 1992. Critical review: the health
significance of environmental odor pollution. Arch
Environ Health 47(1):7687.
Simpson A, Custovic A. 2004. Allergen avoidance in the
primary prevention of asthma. Curr Opin Allergy Clin
Immunol 4(1):4551.
Song BJ, Liu AH. 2003. Metropolitan endotoxin
exposure, allergy and asthma. Curr Opin Allergy Clin
Immunol 3(5):3315.
Spektor DM, Thurston GD, Mao J, He D, Hayes C,
Lippmann M. 1991. Effects of single- and multiday
ozone exposures on respiratory function in active
normal children. Environ Res 55:10722.
Sporik R, Holgate ST, Platts-Mills TA, Cogswell JJ. 1990.
Exposure to house-dust mite allergen (Der p I) and the
development of asthma in childhood. A prospective
study. N Engl J Med 323:5027.
Tager IB, Hanrahan JP, Tosteson TD, Castile RG, Brown
RW, Weiss ST, et al. 1993. Lung function, pre- and
post-natal smoke exposure, and wheezing in the first
year of life. Am Rev Respir Dis 147(4):8117.
Taylor AN. 2001. Role of human leukocyte antigen
phenotype and exposure in development of occupational
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Togias A. 2003. Rhinitis and asthma: evidence for
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111(6):117183.
Table of Tables
Table
Title
Number
1
Posttest
Posttest
1.
2.
4.
5.
6.
8.
9.
Epistaxis.
COPD.
Pulmonary embolism.
Cough and wheezing secondary to ACE inhibitors.
exposure to
A.
B.
C.
D.
Latex.
Spider mites.
Diisocyanates.
Epoxy.
Tobacco smoke.
Pets.
Bedding and laundering practices.
All of the above.
Dust Mites
Have you noticed whether dust exposure makes your
childs asthma worse?
Yes
No
Not sure
Have you used any means for dust mite control?
Yes
No
Not sure
Additional Questions:
Animal Allergens
Do you have any furry pets?
Yes
No
Not sure
Have you seen rats or mice in the home?
Yes
No
Not sure
Additional Questions:
What type of furry pet(s) do you have? (and how many of each)
___________________________________________________
Is it a
o strictly indoor pet? __________
o outdoor? __________
o indoor/outdoor? __________
How often do you wash your pet? __________
How long have you had your pet (s)? __________________________
Has your childs asthma become worse since having the pet? _______
Has your childs asthma become better since moving the pet outside?
________________________________________________________
Have you noticed any rodents indoors or outside your home (rats,
mice)?
Yes
No
Not sure
Cockroach Allergen
Have you seen cockroaches in your home on a regular
basis?
(i e weekly or daily)
Additional Questions:
No
Not sure
Mold/Mildew
Do you see or smell mold/mildew in your home?
Yes
No
Not sure
Is there evidence of water damage in your home?
Yes
No
Not sure
Additional Questions:
Do you use a humidifier or swamp cooler?
Garage
Laundry room
Other
Not sure
No
No
Not sure
Air Pollution
Have you had new carpets, paint, or other changes made to your house in
the past year?
Yes
No
Not sure
Does your child or another family member have a hobby that uses toxic
materials?
Yes
No
Not sure
No
Not sure
Does your child play outdoors when an Air Quality Alert (i.e., ozone,
particulate) is issued?
Yes
No
Not sure
No
Not sure
Do you use unvented appliances such as a gas stove for heating your home?
Yes
No
Not sure
Additional Questions:
Indoor Air Pollution Questions
No
Not sure
Yes
No
Not sure
No
Not sure
If you have a wood burning fireplace or stove, how many times per
month in the winter do you use it? __________
No
Not sure
No
Not sure
No
Not sure
No
Not sure